Primary care update on kidney and bladder cancer: a urologic perspective

The past decade has witnessed many substantive changes in the approach to the diagnosis and treatment of both kidney and bladder cancer. In part, this is based on changes in the understanding of their carcinogenesis and pathogenesis, an appreciation of new concepts in their classification, and the incorporation of new technologies that have emerged. This article reviews advances and updates changes that have been made in the understanding of and approaches to these malignancies from the perspective of their urologic assessment and management while in the context of primary care issues.

Surveillance and management of recurrence for upper tract transitional cell carcinoma

Surveillance of treated upper tract TCC must be tailored to each patient based on individual tumor characteristics. Important risk factors include tumor stage, grade, and multifocality. Molecular markers for TCC may assist in future surveillance strategies, but for now remain experimental. Improvements in imaging eventually may provide the sensitivity needed to determine tumor stage, which would make both initial and recurrence management decisions much more accurate. Initial surgical treatment will influence surveillance when it pertains to superficial disease treated conservatively with either open segmental resection or, now more commonly, with endoscopic resection. Patients treated in this manner require vigilant surveillance of the ipsilateral ureter. Direct visualization in combination with cytology currently appears to be the most effective method, using the same timelines as those used for bladder TCC. Prospective studies concerning surveillance protocols for upper tract TCC would certainly provide more evidence for the current recommendations. However, the evidence does show that upper tract TCC behaves biologically much in the same fashion as does bladder TCC. In light of this fact, the current recommendations are meant to suggest following a patient after treatment for upper tract TCC in a manner similar to that used to follow a patient after treatment of bladder TCC, with individual strategies based on tumor characteristics. For superficial disease, the technology now exists to moniter a patient after endoscopic resection of an upper tract tumor in exactly the same manner used to follow a patient after endoscopic resection of a bladder tumor.

Putative protein markers in the sera of men with prostatic neoplasms

OBJECTIVE

To describe the preliminary identification of serum proteins that may be diagnostic markers in prostate cancer.

PATIENTS AND METHODS

The study included 11 men referred for treatment of localized prostate cancer, 12 with benign prostatic hyperplasia (BPH) and 12 disease-free controls. For serum protein analysis, the protein-chip array surface-enhanced laser desorption/ionization (SELDI) technique was used (Ciphergen Biosystems, Fremont, CA). SELDI combines protein-chip technology with time-of-flight mass spectrometry, and offers the advantages of speed, simplicity and sensitivity.

RESULTS

Three protein peaks were identified in the serum of men with prostate cancer and BPH, but not in controls, with relative molecular masses of 15.2, 15.9 and 17.5 kDa. These three proteins were significantly associated with BPH and prostate cancer when compared with controls (P = 0.001, 0.004, and 0.011, respectively, Kruskal-Wallis test). Interestingly, the 17.5 kDa protein was more abundant in five men with stage T1 prostate cancer than in eight with stage T2 (P = 0.016, two tailed Mann-Whitney U-test corrected for ties).

CONCLUSIONS

These proteins, particularly the 15.9 kDa one, may be used for the diagnosis or monitoring of prostate cancer and differentiation from BPH, and have the potential for antibody-based chip SELDI-TOF technology. Identified proteins may be targets for immunotherapy.

Molecular pathology of non-invasive urothelial carcinomas (part I)

An international consultation on the diagnosis of non-invasive urothelial neoplasms was held in Ancona, Italy in May 2001. Besides histology and problems of classification, one group of experts (Committee no. 3) discussed the molecular pathology and cytometry of non-invasive urothelial carcinomas. In the following first part, special immunohistochemical and molecular markers for stratifications in bladder cancer were discussed including different cytokeratins (clone 34betaE12, CK 20), cell proliferation markers (Ki67/MIB-1, PCNA, AgNOR, DNA-cytometry), tumor suppressor genes and oncogenes (p53, p21, erb-B2, bcl-2), different receptor expressions of epidermal growth factor and vascular endothelial growth factor and others. These molecular markers were analyzed in diagnosis of urothelial carcinomas, recurrences, progression and response to treatment.

Elevated serum triiodothyronine (t3) in Ashkenazi Jewish prostate cancer patients carrying the I1307k allele of the APC (adenopolyposis coli) gene

PURPOSE

The risk of developing any cancer in carriers of the I1307K mutation of the adenopolyposis coli (APC) gene is significantly increased (odds ratio 1.5, P = 0.01). One of the cancers associated with the I1307K mutation is prostate cancer (odds ratio 2.0, P = 0.14). Also, there is an association of APC mutations with thyroid cancer. In this study, we measured triiodothyronine (t3) levels in Ashkenazi Jewish prostate cancer patients, with and without the I1307K mutation of the APC gene.

MATERIALS AND METHODS

Participants in our study were found through urology and radiation oncology clinics in 1999 and 2000. All eligible patients were asked to take part. All patients had been initially diagnosed on the basis of rising PSA or abnormal physical examination. Histological confirmation of diagnosis was obtained for all subjects. Ethnic background was confirmed for all subjects by self-report or interview. The I1307K allele of the APC gene was detected by amplification of DNA isolated from peripheral blood according to standard polymerase chain reaction (PCR) and dot blot procedures. Serum t3 level was determined by fluorescent immunoassay with a standard, commercially available instrument.

RESULTS

We studied 77 patients. The youngest patient was 46, the oldest 88, average age 67 +/- 7.2 (mean +/- SD). Eleven males carrying the APCI 1307K allele had significantly higher serum t3 levels than 66 males carrying the wild type allele. There were no homozygotes for the I1307K allele. None of the males had a t3 level that was above the normal range for our laboratory (137 ng/dl).

CONCLUSIONS

Our findings of increased serum t3 level with the APC I1307K allele in prostate cancer patients is not surprising, given the mitogenic potential of t3. Further studies may clarify whether t3 elevation is the mechanism whereby APC gene mutations increase the risk of prostate cancer, or whether other pathophysiologic abnormalities are involved.

Association between serum triiodothyronine (t3) level and risk of disease recurrence in men with localized prostate cancer

We assessed the relationship of serum triiodothyronine (t3) level and risk of disease recurrence in men treated for localized prostate cancer. Participants in our study were found through urology and radiation oncology clinics, and all eligible patients were asked to take part. All patients had been initially diagnosed on the basis of rising prostate specific antigen (PSA) or abnormal physical examination. Histological confirmation of diagnosis was obtained for all subjects. Serum (t3) level was determined by chemoluminescent assay with a standard, commercially available instrument (Immulite Diagnostic Products Corporation, Los Angeles, California). Sixty-eight men with prostate cancer were studied. In our treatment protocol, patients are divided into three risk groups: low risk: serum PSA</=10, stage</=T2a, or Gleason grade</=6. These patients are treated with a radioactive implant; moderate risk: serum PSA 10-15 or Gleason 7 or stage</=T2b. These patients are treated with 3 months of combined hormonal therapy followed by an implant; high risk: Gleason >7, tumor in seminal vesicle biopsy, serum PSA >15 or stage T2c or T3. These patients are treated with 3 months combined hormonal therapy, an implant, and after 2 months break 6000 rad external beam radiotherapy. There was a significant increase in serum t3 with risk category (P=0.011). Tukey's multiple range B-test showed a significant difference between the t3 levels of the high risk patients, when compared to the t3 levels of the moderate (P=0.013) and low risk patients (P=0.041). The range test showed no significant difference between the t3 levels of the moderate and low risk patients (P=0.897). Because t3 levels may be affected by age, we performed multivariate linear regression, with t3 as the dependent variable. There was a statistically significant (P=0.035) association of t3 level with risk group, but there was no significant association of t3 with age (P=0.803). Multivariate linear regression, with t3 as dependent variable, PSA, Gleason score, and stage as independent variables showed a significant overall association of the three independent variables with t3 (P=0.042), though individually the relationships were not significant. None of the men had a t3 level that was above the normal range for our laboratory (137 ng/dl). Urologists are actively seeking additional biomarkers of prostate cancer aggressiveness. Many prostate cancers are quite indolent and may never cause a problem, but it is impossible to identify such tumors with certainty. Further studies of serum t3 level as a biomarker in prostate cancer might therefore be worthwhile. With more and better biomarkers, many older men might be spared the rigors of radiation therapy and/or surgery and the complications. Also, new prostate cancer therapies might be directed toward inhibiting the mitogenic effects of t3.Prostate Cancer and Prostatic Diseases (2001) 4, 232-234.

Serum triiodothyronine is increased in men with prostate cancer and benign prostatic hyperplasia

Triiodothyronine is the active thyroid hormone produced by de-iodination of the precursor thyroxine that is necessary for the growth of prostate cancer cells in vitro. For this reason we assessed serum triiodothyronine levels in men with localized prostate cancer, benign prostatic hyperplasia (BPH) and controls in the same age group.

MATERIALS AND METHODS

We studied 161 men referred for treatment of localized prostate cancer, 20 with BPH and 27 controls. Serum triiodothyronine was determined by fluorometric immunoassay and a commercially available instrument.

RESULTS

Men with BPH had the highest triiodothyronine levels, followed by those with prostate cancer. Controls had the lowest triiodothyronine. There was significant triiodothyronine variation among the 3 groups (1-way ANOVA p = 0.001). In men with BPH serum triiodothyronine was significantly different from that in men with prostate cancer (Tukey's multiple range test p = 0.013). Men with prostate cancer had serum triiodothyronine that was significantly different than in controls (p = 0.048), as did those with BPH (p <0.001). Because serum triiodothyronine normally decreases with age, we performed multivariate analysis of variance controlling for age. There was a significant decrease in serum triiodothyronine with age (p = 0.020). There was also significant triiodothyronine variation among the 3 subject groups independent of age (p <0.001).

CONCLUSIONS

Urologists are actively seeking additional biomarkers of prostate cancer aggressiveness. Many prostate cancers are quite indolent and may never cause a problem but it is impossible to identify such tumors with certainty. With more and better biomarkers many older men with prostate cancer may be spared the rigors of radiation therapy and/or surgery as well as complications. Triiodothyronine may be such a biomarker. Also, new prostate cancer and BPH therapies may be directed toward inhibiting the mitogenic effects of triiodothyronine.